Referral Form

PLEASE NOTE

THIS ONLINE FORM IS FOR PATIENTS WHO ARE SELF REFERRING ONLY

IF YOU ARE A PROFESSIONAL PLEASE DOWNLOAD AND COMPLETE THE PROFESSIONAL’S REFERRAL FORM BELOW

PROFESSIONAL REFERRAL FORM - https://shorturl.at/cnB24

LTC PROFESSIONAL REFERRAL FORM - https://shorturl.at/givwx

This self-referral form is a way for you to access psychological support and advice from your local talking therapies service. The service is for people who are having emotional difficulties and are struggling to cope with everyday life. If you have a history of serious mental health issues, it is possible we’re not best suited to help you and we suggest you go to your GP for advice.

We are not able to provide immediate support in an emergency. If you require immediate help please contact your GP, or your local Accident & Emergency Department, or Call the Oxleas 24- hour Mental Health Crisis Line on 0800 330 8530.

Through completing this form, you are consenting to have this information stored confidentially on a secure electronic system separate from your GP’s system, and for your GP to be informed of your contact with us.

If you are unable to complete this form for any reason or if you would prefer to give these details over the phone please call 0203 260 1100 or email us on oxl-tr.greenwichtimetotalk@nhs.net

By providing these details you are giving us consent to contact to you regarding confidential information.

If you are a Carer/Guardian completing this form on behalf of the patient, please provide the patient contact details below.

If you would like to add your contact information, please provide in 'other contact' details.

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Do you require an interpreter?:*

Yes

No

Preferred Language:

NHS Number:

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Phone Number:

Phone Type:

Can we leave a voicemail?:

Yes

No

Mobile Number:*

Can we leave a voicemail?:*

Yes

No

Can we send Text Message reminders?:*

Yes

No

Email Address:*

Can we correspond with you via email?:*

Yes

No

Ethnicity:*

Sexuality:*

Do you have a disability?:*

Do you have any specific needs we need to be aware of?:

Registered GP Name:*

Registered GP Surgery Name and Address:*

Please select from the following drop down list the reason that best describes why you are referring:*

Are you currently a mental health inpatient under the care of a Community Mental Health Team or receiving psychological therapies elsewhere?:*

Yes

No

Do you have any long-term physical health conditions?:*

If you have more than one long term condition select the issue that presents the most difficulties at the time.

If other please describe:

Is your long-term physical health condition the main reason for your referral?:*

Yes

No

Are you, or your partner pregnant?:*

I am pregnant

My partner is pregnant

No

N/A

How many children do you have age 1 and under?:

How many children do you age 5 and under?:

Are you an ex-British Armed Forces member?:*

Do you have any accessibility requirements?:*

Yes

No

Not sure

If yes, please state your requirements:

Is there anything you would like us to know?:

In order to reduce your wait for the service, we now work in partnership with Xyla Digital Therapies. This service offers timely assessments and treatments. Do you consent to being contacted by this service if appropriate?:*

Yes

No

Greenwich Time to Talk offers employment support alongside therapy. This can be to help you find work, support to return from sick leave or to resolve concerns that are making it difficult to remain in work.

Is this something you would be interested in accessing?*

Yes

No

Do you work for the NHS? (for example an NHS Trust, primary care or a charity funded by primary care, CCG etc):*

Yes

No

Do you work in Social Care (for example you work for the local authority, in a care home or providing care for residents at home?):*

Yes

No

If you are a 16/17 year old, or a parent of a 16/17 year old, please answer these questions:

PARENT: Are you making this referral on behalf of the young person?*

Yes

No

N/A

If you have answered yes, has the young person given permission for you to make this referral?*

Yes

No

N/A

YOUNG PERSON: Are your parents/carers aware that you are making this referral?*

Yes

No

N/A

If yes, do we have your consent to speak to your parents on your behalf?*

Yes

No

N/A

Name:

Contact Number:

Relationship:

Where did you hear about us?:*

If other, please specify:

We anonymously share data from our service with NHS England and other statutory bodies that monitor our performance. This information may include number of people we see, what type of treatment they receive, or if they recovered. This does not include personally identifying information such as your name, address, contact details, etc. If you wish to opt out of NHS data sharing please copy and paste the following link to a new web browser www.nhs.uk/using-the-nhs/about-the-nhs/opt-out-of-sharing-your-health-records/

Please complete the captcha

Referral Form for Greenwich Time to Talk NHS Talking Therapies

Personal Details

GP Details

Referral Information

Further Information

Other Contact Details